Otolaryngology Coding Alert

There is no specific CPT code for late repair of nasal fracture. As a result, otolaryngologists have no option but to choose from two imperfect series of codesrhinoplasty (30400-30420), which includes elements that usually dont apply to a late repair of nasal fracture only, and treatment of nasal bone fracture, which doesnt reflect the extra work performed by the otolaryngologist in refracturing the bone.

Although coding specialists tend to agree that either series is likely to be reimbursed if the procedure is documented carefully and completely, theyre split on which series of codes actually should be used.

Otolaryngologists may perform late fracture repair for a variety of reasons, which essentially fall into two categories: (i) severe swelling does not permit acute fracture repair (usually closed) to be performed; or (ii) the dorsum (nasal bone) may have healed incorrectly, either on its own or after a closed repair.

Coding Can Be Confusing

For example, a 15-year-old boy breaks his nose while away at school. The nose is reduced (21315, closed treatment of nasal bone fracture; without stabilization), but a few months later when he returns home and visits the familys otolaryngologist, the nose still is out of place. So the otolaryngologist performs an open repair of the nasal fracture by opening the boys nose, refracturing the dorsum and then reducing it.

Choosing a code in this situation can be a vexing problem. At first glance, repair of nasal fracture might seem the obvious choiceafter all, the physician is fixing a broken nosebut American Academy of Facial Plastic and Reconstructive Surgery (AAFPRC) coding guidelines clearly state that nasal fracture codes should be used to describe the handling of acute fractures only. Treatment of healed fractures and the sequelae of trauma, such as malunion and nasal airway obstruction, are coded using the rhinoplasty series.

Once the fracture heals, says Laurel Ferris, MA, CPC, an independent facial plastic coding specialist in Edina, Minn., It is no longer acute, and youre no longer dealing with a fracture but with the late effects of a fracture. If youre beyond the healing stage, you should use a rhinoplasty code.

The use of the term acute, however, comes with its own problems. The AAFPRC guidelines dont spell out exactly how many days a fracture can be termed acute, and although the fracture may not heal for two to three weeks, some coders make the window much shorter, as little as five to six days. After that, if the otolaryngologist performs a nasal fracture repair, they bill it as a rhinoplasty.

Ferris notes that both the AAFPRC and the American Society of Plastic Surgeons indicate that if the fracture no longer moves, it doesnt qualify as acute. By six weeks any repairs should be coded with rhinoplasty codes, she says, noting that in severe cases, the surgeon may wait three to six weeks for the bone to repair itself and then schedule rhinoseptoplasty in three to six months.

If the AAFPRC guidelines are followed, the most likely rhinoplasty code in this scenario would be 30400 (rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip), which is the least complicated of the primary codes in this series. If the boys septum also required significant work, 30420 (rhinoplasty, primary; including major septal repair) would be the appropriate code.

Coding as Nasal Fracture

Coding this procedure a rhinoplasty, however, is far from accurate. There is no way that if all you do is reset the dorsum and the septum, that any rhinoplasty code accurately describes what you did, says Lee Eisenberg, MD, an otolaryngologist in Englewood, N.J., and a member of CPTs executive committee and editorial panel.

There is a lot more involved in performing a rhinoplasty than just opening the nose and fracturing and repairing the dorsum, Eisenberg says, noting that even the simplest rhinoplasty code, 30400, includes elements that have not been performed in this situation.

The problem is that there is no code just for repairing nasal bones other than the nasal fracture codes. As long as its well documented that injury to nasal dorsum and/or septum is from a traumatic injury and all youre going to do is perform an open fracture of the nasal bones, then its appropriate to bill open treatment of nasal fracture, he says.

Determining whether a procedure should be coded as rhinoplasty or treatment of nasal fracture depends on what you did, says Randa Blackwell, a coding specialist with the department of otolaryngology at the University of Maryland in Baltimore. If you go in and there is bone deformity, for example, then rhinoplasty is appropriate. But if only the nasal repair is performed, the procedure should be billed as an open reduction of nasal fracture. She notes that in the example above, the otolaryngologist likely will rebreak the dorsum in the same place as the original break and that no other reshaping of the nose will occur.

Ferris acknowledges that the primary rhinoplasty codes, as listed in CPT 2000, are problematic because they originally were designed for cosmetic, not functional, rhinoplasty. The rhinoplasty codes dont accurately describe a functional rhinoplasty. Its been a thorn in the side of rhinoplastic surgeons that the codes they are forced to use for functional rhinoplasty are inadequate.

This inadequacy, Eisenberg points out, means that if 30520 (septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft) or the other rhinoplasty codes are used, modifier -52 (reduced services) would need to be attached to indicate that the complete procedure was not performed.
Instead, he says, when billing for the nasal repair in the example above, otolaryngologists should use code 21325 (open treatment of nasal fracture, uncomplicated) or 21330 (open treatment of nasal fracture, complicated, with internal and/or external skeletal fixation). If the septum also required repair, 21335 (open treatment of nasal fracture, with concomitant open treatment of fractured septum) should be used.

Eisenberg notes that open reductions often are not performed on acute fractures, which in itself indicates that they were designed, at least in part, for the purpose of coding a late repair.

Open reductions usually occur after two or more weeks, when theres enough healing that the otolaryngologist can no longer perform a closed reduction, he says. Another reason to wait and subsequently perform an open repair is with patients suffering from a head injury. In those cases, Its not worth putting the patient at risk by sedating them for the closed procedure. Instead, the physician will wait and then perform an open procedure at a later date.

Coding as Rhinoplasty

Rhinoplasty codes may include too much, but nasal fracture codes do not include enough, Ferris says, noting that these codes dont adequately describe the extent of what the otolaryngologist did.

The otolaryngologist who is repairing a nasal bone that has already healed has to refracture the bone, and that is not described in treatment of nasal fracture codes, Ferris says. Breaking the bone again is more work and entails more risk, and surgeons should get paid for that.

She notes that billing for a rhinoplasty instead of treatment of nasal fracture goes a long way toward reimbursing the physician correctly for the extra work, effort and risk because it pays at a higher level than equivalent treatment of nasal fracture codes.

If you compare 21335 vs. 30420 (both of which include open repair of the dorsum and septum), 21335 has 19.64 RVUs, whereas 30420 has 35.57, reflecting the fact that its a bigger deal surgically. The surgeon actually has to do morebreak the bone and then carefully reset itthan when an acute fracture is performed, Ferris explains.

In addition, treatment of nasal repair codes dont take into account any additional repairs of the nose that the otolaryngologist may need to perform, Ferris says, resulting in undercoding and, most likely, inadequate payment.

Precise Documentation Is Key

Regardless of which procedure is billed, the carrier likely will request supporting documentation to indicate medical necessity. Many payers consider rhinoplasty procedures as cosmetic and routinely deny claims or impose strict documentation/medical necessity requirements. As a result, many otolaryngologists tend to shy away from using these codes.

Physicians love to use fracture repair codes because they tend not to be screened by insurance carriers, Ferris says. But most health insurers now are rather leery of doctors evading the use of rhinoplasty codes by billing for repair of a fracture.

Blackwell notes, however, that many otolaryngologists are unaware that rhinoplasty codes can be used for functional as well as cosmetic purposes, in effect echoing the previously cited concern of plastic surgeons that the CPT descriptors were designed mainly with cosmetic rhinoplasties in mind.

Eisenberg, meanwhile, points out that documentation requirements for using nasal fracture codes for a healed repair are stringent in themselves. These codes must be supported by accurate and complete documentation that indicates why the open reduction was performed after the bone already healed, he says.

As always, the operative report must match the procedures being coded. To ensure that occurs, otolaryngologists should choose the words they use to describe procedures and indications carefully. For example, if procedure 21335 (open treatment of nasal fracture; with concomitant open treatment of fractured septum) is coded, the operative report should not say that the physician performed an open reduction of a nasal fracture and a septoplasty, but rather a septal repair or septal reduction because the reference to septoplasty will raise eyebrows when it is reviewed or audited.

The documentation also should include the correct diagnosis codes for the procedure in question. Associated ICD-9 codes vary among the different procedures, but all include the following:

470deviated nasal septum
802.0nasal bones, closed fracture
802.1nasal bones, open fracture

Other codes applicable to one or more of the nasal fracture CPT codes are:

733.82nonunion of fracture
802.8other facial bones, closed fracture
873.30open wound of nose, unspecified site, complicated
873.31open wound of nasal septum, complicated
873.32open wound of nasal cavity, complicated

For rhinoplasty, the applicable ICD-9 codes are:

213.0benign neoplasm of bones of skull and face
478.1other diseases of nasal cavity and sinuses
738.0acquired deformity of nose
873.3open wound of nose, complicated
905.0late effect of fracture of skull and face bones
925.1crushing injury of face and scalp

Note: Other ICD-9 codes crosslink to rhinoplasty procedures but are not associated with nasal fracture repair.

Modifiers Help Clarify

Nasal fractures often are accompanied by fractures of the septum, and code 30420 addresses this by adding including major septal repair to the code. But, whether due to error (indenting 30410, which Eisenberg says should not be indented and should be the base code for 30420) or oversight (the elements of the rhinoplasty were left out), the net result is that the rhinoplasty portion of this code has no descriptor at all. This promotes coding assumptions and errors, even though medical experience and common sense should indicate that at the very least, a rhinoplasty has to satisfy the elements outlined in 30400.

Given the basic rhinoplasty elements, Ferris concedes that modifier -52 (reduced services) would be appropriate if the otolaryngologist only repaired the nasal fracture (and septum). But, she says, doing so should not necessarily change how the claim is paid.

Other coding specialists disagree. When you put modifier -52 on a claim, most carriers will want to take a look at how much of the procedure was performed and how much wasnt, says Susan Callaway-Stradley, CPC, CSS-P, a coding and reimbursement specialist in North Augusta, S.C.

In this instance, however, having the carrier scrutinize the claim may not be such a bad thing, Callaway-Stradley says. In view of the inadequacy of both series of codes, she also recommends using modifier -22 (unusual procedural service) if treatment of nasal fracture codes are used to recognize the additional work and risk in refracturing the nasal bone before the open reduction is performed.

In both cases, claims will not be paid without carrier review, so you cant be accused of fraud because the carrier will already have seen the claim and the supporting documentation, she says.

Note: The following coding specialists also contributed to this story: Margaret M. Hickey, RN, MSN, MS, president of the Society of Otorhinolaryngology and Head-Neck Nurses and clinical oncology director at the Tulane Cancer Center in New Orleans; Gretchen Segado, CPC, assistant compliance officer at Thomas Jefferson University in Philadelphia; Barbara Cobuzzi, MBA, CPC, CPC-H, a coding and reimbursement specialist in Lakewood, N.J.; and Ann Hughes, CPC, coder for Mid-Vermont ENT in Rutland, Vt.